REVIEW PAPER International Journal of Occupational Medicine and Environmental Health 2019;32(5):585 – 593 https://doi.org/10.13075/ijomeh.1896.01398 TRAUMATIC KNEE INJURY PATTERNS IN ANATOLIAN FOLK DANCERS: A CASE SERIES AND LITERATURE REVIEW NESLIHAN AKSU1, BUSRA AKGONUL2, TANER AKSU3, VEFA ATANSAY1, and AYHAN NEDIM KARA1 1 Istanbul Bilim University, Istanbul, Turkey Faculty of Medicine, Department of Orthopedics and Traumatology 2 Sisli Florence Nightingale Hospital, Istanbul, Turkey Department of Physical Therapy and Rehabilitation Department 3 Bahcesehir University, Istanbul, Turkey Medical Faculty, Orthopedics and Traumatology Department Abstract Lower extremities, especially the knee region, are susceptible to traumatic injuries because of long-lasting hard landings and impacts. Most of the injuries described in the literature are associated with ballet. In this review study, the authors tried to present the traumatic knee injury patterns of the Anatolian folk dance. The Fire of Anatolia dance group consists of 82 dancers (37 males [45.1%] and 45 females [54.9%]) with the mean age of 27.96 (SD = 5.05) years (range: 18–38 years). The major folk dances of the region are Zeybek, Halay, Horon, Teke, Roman, Karsilama, Bar and Lezginka (“the Caucasian”). The dancers suffered from 9 orthopedic injuries requiring surgical treatment (3 meniscus tears, 4 anterior cruciate liga- ment tears, 1 posterior cruciate ligament tear, 1 patellar dislocation) during a 10-year period. The authors investigated solely the traumatic injuries of these folk dance styles and aimed at revealing the traumatic knee injury patterns in this case series and literature review. On the one hand, the Anatolian folk dancers experienced meniscus tears following frequent squats and twists on single leg stances, typical of Horon and Zeybek. On the other hand, anterior cruciate tears happened after jumps and landings in the Caucasian (Lezginka jump) dance. A posterior cruciate ligament tear was also seen after the Caucasian dance landing. The split figure in the Karsilama dance ended up with patellar dislocation. Certain dance figures seem to be related to specific types of injuries. Int J Occup Med Environ Health. 2019;32(5):585 –93 Key words: dance injury, patellar dislocation, meniscus tear, knee injury, anterior cruciate ligament injury, posterior cruciate ligament injury INTRODUCTION previous studies (7–29%) [1–6]. Knee problems account Most of the injuries described in the literature are associ- for 14–20% of all complaints and > 50% of them are ret- ated with ballet [1–8]. In the present study, the foot and ropatellar (synovial plica, medial chondromalacia, lateral ankle was the most common site (40%), which falls within patellar facet syndrome, patellar subluxation, fat pad syn- the range reported in previous studies (15–66%) [1]. In the drome) in ballet dancers [7]. Knee injuries in ballet danc- present study, the knee was the third most commonly in- ers have been reported in the literature with the following jured location (16%), falling within the range reported in prevalence: peripatellar knee pain (51–57%), ligamentous This article’s abstract was presented for an oral presentation at the APOA (20th Asia Pacific Orthopaedic Associations) 2018 Conference. Received: October 28, 2018. Accepted: July 10, 2019. Corresponding author: Neslihan Aksu, Istanbul Bilim University, Faculty of Medicine, Department of Orthopaedics and Traumatology, Abide i Hurriyet Cad No 164 Sisli 34381 Istanbul, Turkey (e-mail: [email protected]). Nofer Institute of Occupational Medicine, Łódź, Poland 585 REVIEW PAPER N. AKSU ET AL. sprain (10–24%), patellar tendinitis (8–15%), iliotibial Anatolian folk dances band syndrome (4–11%), pes anserine tendinitis (2–5%), The major folk dances in the Anatolian region are Zey- popliteal cyst (0–2%), and torn meniscus (1–2%) [7]. The bek, Halay, Horon, Teke, Roman, Karsilama, Bar and the prevalence of injuries sustained by professional dancers Lezginka (“the Caucasian”) [10–14]. The Fire of Anatolia belonging to a major Spanish ballet company practicing dance group is a leading professional dance group of the classical, neoclassical, contemporary, and Spanish dance region, which performs dances of various ethnic groups were acute traumatic in 24.7%, and nontraumatic overuse which have dwelt in Anatolia for centuries and still live to- in 75.3% of the cases [8]. This study showed that 18% of gether. The names of the folk dances in this region, based the 366 injuries were in the knee region which included on their region of origin, are as follows: Zeybek (Aegean patellofemoral syndrome (8.2%), patellar tendinitis and Western Anatolia), Halay (Central and Southern (6.8%), chondral lesions (3%), and quadriceps muscle in- Anatolia), Horon (Eastern Black Sea), Teke (Southern jury (1.1%) [8]. Anatolia), Roman and Karsilama (Thracian), Bar (North- The literature is scarce, with only 2 articles concerning ern Anatolia), and Lezginka (Eastern Anatolia) [10–14]. traumatic knee injuries leading to surgery in this group While the boundaries of the dances can be defined as of patients. One of them was written by Mauffels [9] and above, it is hard to establish a definite boundary for the included 4 professional ballet dancers who had their an- Anatolian folk dances. The music has a 6/8 rhythm, the terior cruciate ligament reconstructed, and the other was melody is clear and dynamic, and the pace is fast [11]. drawn up by Aksu [10] and provided descriptions of knee Halay is the most widely known and performed type of the injuries in 7 professional folk dancers (2 anterior cruci- Anatolian folk dances. During the dance, male and female ate ligament injuries, 1 posterior cruciate ligament recon- dancers are lined up in turns to form a straight line while struction, 3 meniscus repair cases, and 1 medial patello- holding each other by the hand. The dance starts with slow femoral ligament repair). In this case series and literature steps and gradually speeds up. The steps of the Halay dance review study, the authors tried to present the traumatic are usually based on foot figures [11–14]. The final dance knee injury patterns typical of the Anatolian folk dance. in this dance group is Garzane Halay, taking its name from the Garzane region of the Bitlis Province in Eastern Ana- METHODS tolia [12]. There are consistent shoulder shakes, hard foot The Fire of Anatolia dance group consists of 82 dancers figures and soft head movements in the Garzane Halay. (37 males [45.1%] and 45 females [54.9%]) with a mean In the finale, the dancers hold each other by the hand and age of 27.96 (SD = 5.05) years (range: 18–38 years). The jump together; this is called the Garzane jump. The moves dancers suffered from 9 orthopedic injuries requiring in the Bitlis Halay are rich in terms of choreography. There surgical treatment (3 meniscus tears, 4 anterior cruciate are several forms of line-ups. The dancing couples jump ligament tears, 1 of which involved a posterolateral cor- and clap while standing next to each other [12]. ner tear, 1 posterior cruciate ligament tear, and 1 patellar Horon is a lively folk dance of the Black Sea region of dislocation) during a 10-year period. The authors inves- Anatolia, performed to kamancheh and drum music. The tigated solely the traumatic injuries of these folk dance physical features of Horon dancers are anthropometrical- styles and aimed at revealing traumatic knee injury pat- ly more defined than those of Halay dancers, thanks to the terns. They had previously obtained informed consents of high tempo of the music [12–14]. Their body fat percent- all the subjects involved in this study. ages and circumferences are lower than those of the Halay 586 IJOMEH 2019;32(5) TRAUMATIC KNEE INJURY PATTERNS IN ANATOLIAN FOLK DANCERS REVIEW PAPER dancers [12,14]. Dancers in this group can reach a pace joint. Meniscal injuries typically occur following the en- of 218 steps/min during performance as was recorded by trapment of the meniscus between the femoral condyle a step counter [11]. and the tibial plateau during a turn on a flexed knee. Zeybek is a folk dance of the Aegean region. The dance A forceful flexion causes pain in the posterior horn rup- may be performed solo or by a circle of singles. When per- ture; similarly, a forceful extension causes pain in the an- formed by a group, dancers dance Zeybek without holding terior horn rupture. Meniscal tears result from percussive each other [12,14]. squats or from “screwing the knee” to increase turnout in Bar is one of the folk dances of the Northeastern Anato- ballet trainees [15]. lia. Dancers form lines to perform these esthetic dances In folk dances, meniscal tears occur due to forceful squat- of nobility and bravery. The dances depict tales of victories ting and standing, or turning on a fixed foot. Folk dances of war, valor and heroism [12,14]. are characterized by much faster and harder knee move- Teke is a folk dance performed by Turkmens in Southern ments than ballet. The Halay and Horon dances have fast Anatolia. It has 3 main sections: wobbling, hopping on and pounding feet moves [12,13]. Horon has been shown 1 foot, and running away like a cantering horse [14]. to be the fastest dance in the world, with 218 steps/min [9]. Lezginka, also called “the Caucasian” in the Caucasus re- Unlike ballet dancers, folk dancers do not tiptoe or per- gion, is a solo pair dance. The dance is a half-solo half- form movements that force the lower extremity to exces- group performance in which young people can show their sive external rotation. Of all the Anatolian folk dances, skills individually. In some jumps, the dancer lands on his the Roman dance has particularly frequent moves with knees, jumps up and lands on his knees again [10,11].